Emergency lectures - India tox
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  • SIGNS/SYMPTOMS Loss of appetite, tachycardia, sweating, dilated pupils, tremors, ?psychosis Pt is prone to violence - BE PREPARED
  • Heroin, Morphine, Dilaudid, Methadone. Codeine, Darvon, Demerol Symptoms * RESPIRATORY DEPRESSION Hypotension Pinpoint pupils Look for needle track marks

Transcript

  • 1. Initial Approach to the Poisoned Patient Matthew J. Madden, M.D. PGY-3 Dept. of Emergency Medicine Loma Linda University
  • 2. What we will cover
    • Historical data
    • Initial ED management
    • Toxidrome
    • Toxidrome-physical exam
    • Selected poisonings
  • 3. Some Data
    • 2001 approx. 5% of all ED visits
    • 52% were pediatric patients< 6 yrs old
    • Tyl/Asa= #1
    • Anti-depressants- prozac, zoloft
    • Street drugs- heroin, cocaine
    • CVS
  • 4. Candy?
  • 5. Socrates
    • 399 BC.
    • Ingestion of Hemlock
    • No cure- death in 15 min to 1 hour
  • 6. Jamestown
    • 1978
    • Hundreds died after ingestion of Cyanide
    • Multiple ways to take
    • Gas chamber
    • “Almond” odor in 20-40%
  • 7. Toxidromes
    • Collection of signs and symptoms observed after an ingestion of a particular substance
    • “Fingerprint”
    • Helps establish type of ingestion
  • 8. Initial approach
    • Protect ED personal- may be doctors, nurses, RT’s, police, fire department, etc
    • ABC’s- (How come the Americans always say this?)
  • 9. Initial approach
    • Most patients will have an altered sensorium
  • 10. Differential Dx
    • Infection
    • Sepsis
    • Hypoglycemia
    • Hypothermia
    • Hypoxia
    • Uremia
    • Electrolyte/Endocrine
  • 11. Initial approach
    • ABC’s
  • 12. Initial approach
    • ABC’s
    • History
  • 13. Initial approach
    • ABC’s
    • History
    • VS and exam
  • 14. Initial approach
    • ABC’s
    • History
    • VS and exam
    • “Coma Cocktail” and Activated Charcoal
  • 15. Initial approach
    • ABC’s
    • History
    • VS and exam
    • “Coma Cocktail” and Activated Charcoal
    • Lab studies and ancillary data
  • 16. Initial approach
    • ABC’s
    • History
    • VS and exam
    • “Coma Cocktail” and Activated Charcoal
    • Lab studies and ancillary data
    • Cardiac monitor/ EKG
  • 17. History
    • What?
    • How much?
    • When?
    • Witnesses?
    • Anything else? (drugs?)
    • Prior attempts?
    • Where is the family?
  • 18. VS and Exam
    • Rectal Temp- must know if hyperthermic
    • BP
    • HR- bradycardia
    • RR- is it extremely low?
    • O2%
  • 19. Toxidrome-Oriented Physical Exam
    • Neurologic exam- pupils, mental status
    • Skin- dry vs wet
    • Lungs
    • Examine for bowel sounds- hyper vs hypo-active
    • Essentially an exam of the Autonomic NS
  • 20. Autonomic Nervous System
    • Controls heart rate, blood pressure, pupil size, sweating, smooth muscle (bronchioles) GI/GU peristalsis
    • Balance of parasympathetic/sympathetic influences
    • Drugs or toxins can stimulate or suppress parts of ANS producing syndromes suggestive of certain toxin groups
  • 21. Coma Cocktail
    • DON’T
    • Dextrose
    • Oxygen
    • Narcan
    • Thiamine
  • 22. Charcoal
    • Created by firing various organic material (wood)
    • Steamed at 900 degrees to “activate”
    • Large surface area and absorbs toxin in gut preventing further absorption
    • Creates a “gradient” for blood to gut transport
    • Does NOT work for Lithium, Lead, Iron, Potassium, acids/alkalai
  • 23. Toxidromes
    • Cholinergic
    • Anticholinergic
    • Sympathetomimetic
    • Opioid
  • 24. Cholinergic
    • Organophosphates
    • Is this common in India?
    • SLUDGE
    • Parasympathetic and Sympathetic (secretions)
    • Supportive care
    • Atropine and 2-pam
  • 25. Anticholinergic
    • Atropine like compounds- jimsonweed, antihistamines, belladonna, antidepressants-TCA’s
    • Muscarinic receptors
    • Block cholinergic system
  • 26. Anticholinergics
    • Hot as a Hare- hyperthermic
    • Red as a Beet- flushed skin
    • Dry as a Bone- no sweat
    • Blind as a Bat- myadriasis
    • Mad as a Hatter- hallucinations
  • 27. Anticholinergics
    • Other findings- no bowel sounds
    • EKG- sinus tach most common, beware of TCA’s
    • Labs- normal
    • Test for other toxic components
  • 28. Anticholinergics
    • Treatment- supportive care is usually the only thing required.
    • Activated charcoal
    • Benzodiazepines- lets make them nice and relaxed
    • Cooling measures
  • 29.  
  • 30. Sympathomimetics
    • Sympathetic overload
    • Hypertension
    • Tachycardia
    • Hyperthermia
    • Mydriasis
    • Anxiety/ Delirium
    • Wet skin
  • 31. Sympathomimetics
    • Can cause dysrhythmia’s
    • Some examples include cocaine, amphetamines, ecstacy, diet pills (ephedra)
    • These compounds either directly stimulate sympathetic system or release nor-epi or epinephrine
  • 32. Cocaine
    • Extract of Erythroxylon coca
    • Water soluble
    • Smoked, injected, snorted
    • Ether extraction produces smoked form
    • Nasal 30 min to 1-3 hours
    • IV/Smoked 30sec to 30min
  • 33. Clinical Use
    • Used for nasal surgery
    • Excellent topical anaesthetic and vasoconstrictor
    • Blocks fast Na+ channels
  • 34. Adverse effects
    • Psychomotor agitation
    • Cardiac- aortic dissection, hypertensive emergencies, MI from vasoconstriction
    • Rhabdomyolysis
    • Dysrhythmia
    • Packers vs Stuffers
  • 35. Dysrhythmia
    • Shock resistant Vfib/Vtach
    • QRS prolongation
    • Qtc prolongation
  • 36. Treatment
    • Supportive
    • Nitro
    • Benzo’s
    • NaHCO3- Why?
    • Alpha antagonist
    • No Beta blockers
    • EKG, cardiac enzymes
  • 37. Opioid
    • Heroin, codeine, propoxyphene (darvocet)
    • Characterized:
      • Neurologic depression
      • Pinpoint pupils
      • Respiratory depression- key
  • 38. Opioid
    • Any drug with morphine like quality
    • IV/Oral/Transdermal/SQ
    • Characteristic toxidrome as described
  • 39. Opioid - Treatment
    • 1. AIRWAY, O2 - Wait on intubation until you assess effects of Narcan
    • 2. IV
    • 3. D50W(Coma of unknown cause)
    • 4. Naloxone (Narcan)
    • Titrate with respiratory rate
    • 5. If no response to Narcan, pt may need intubation
  • 40. Management
    • Narcan- should you use to diagnose only or to treat as well?
    • T 1/2 20-60 min.
    • How long does heroin last? (4-5hrs)
    • Up to 4 hours or longer for normal hospital doses
  • 41. Opioid
    • Further studies may include basic labs, urine drug screen, ekg, head ct
  • 42. Complications
    • IV drug use- HIV/Hep C, Bacterial infections, endocarditis, shooter’s abscesses, fecal impaction, gas gangrene
    • Seizures- demerol
    • Pulmonary edema
  • 43. Non- Toxidrome Toxicology
    • Same approach- but can be much harder
    • Additional lab tests may include Arterial blood gases- to asses for metabolic acidosis
    • Lets review the Poisonous alcohols
  • 44. Alcohols
    • Methanol
    • Found in paint, paint thinners, etc
    • Converted to Formic acid and formaldehyde by ADH
    • Toxic accumulation results in retinal edema, optic papillitis
    • GI irritation, CNS depression/ALOC
  • 45. Alcohols
    • Methanol- Wide anion gap acidosis (severe) and high osmolal gap
    • Treatment includes-Fomepazole (newer agent binds alcohol dehydrogenase) dose is 15mg/kg IV load followed by 20mg/kg every 12 hours for 4 hours
    • Ethanol- 0.6g/kg load then 0.11g/kg/h and keep ethanol level at 100-150 mg/dL.
  • 46. Alcohols
    • Definitive Tx is hemodialysis- will eliminate methanol
  • 47. Ethylene glycol
    • Antifreeze, coolants, deicers
    • Three stages
      • I - appears intoxicated
      • II - 12- 14 hours
        • Pulmonary edema
      • III - 24 - 72 hours
        • renal failure
  • 48. Ethylene Glycol
    • Metabolized to glycoaldehyde
    • Then to formic acid, glyoxylic acid, and oxalic acid
    • Lab data reveals a wide anion gap metabolic acidosis and a large osmolal gap
    • No vision changes/disturbances
  • 49. Ethylene glycol
    • Key finding is in the urine
    • Calcium oxalate cystals
    • Wood’s lamp
  • 50. Initial approach
    • ABC’s
    • History
    • VS and exam
    • “Coma Cocktail” and Activated Charcoal
    • Lab studies and ancillary data
    • Cardiac monitor/ EKG
  • 51. Case
    • 25 y.o male was seen sitting on balcony 16 feet above ground earlier in day.
    • “ Friends” found him lying on ground, unconscious 1 hour later. They drag him to ED and leave.
    • What’s your initial approach?
  • 52. Case
    • ABC’s
    • History- nothing there
    • VS and Exam
    • Coma Cocktail
    • Do you need labs?
  • 53. Case
    • You fixed him with Narcan and he wants to leave. Should you let him?
  • 54. Questions?
    • Remember to always do the ABC’s first